FY16 Benefits Information Packet - Frederick County Public Schools


FY16 Benefits Information Packet - Frederick County Public Schools
Frederick County Public Schools
2015 – 2016 Benefits Information
FCPS Benefits Office
191 South East Street 2nd Floor
T (301) 644-5080 F (301) 644-5122
Visit http://www.fcps.org/benefits for more information
Summary of Benefits Plans
UnitedHealthCare Choice Plus Medical Plan
UnitedHealthcare Choice Plus allows you to take advantage of two levels of care benefits:
In-network — Selecting a physician or health care provider within the UnitedHealthcare’s large local and national network means
maximum coverage and lower out-of-pocket expenses. Copayments are charged for eligible services, and referrals are not required for
specialty services.
Out-of-network — Higher deductibles are required and you must file claims for reimbursement of 80% of eligible expenses. Employees
have a $200 deductible and an annual out-of-pocket maximum of $1,250. Family coverage requires a $400 deductible and an annual
out-of-pocket maximum of $2,500.
Primary Care Physician
Outpatient Diagnostic Services
Inpatient Hospital
Emergency Room (Non-Emergency)
No Out-of-Pocket Maximum
20% after deductible
$200 per Covered Person
$400 for all Covered Persons in a family
MAXIMUM OUT-OF-POCKET: $1,250 per Covered Person per policy year
$2,500 for all Covered Persons in a family
Out-of-Pocket Maximum includes the Annual Deductible
UnitedHealthCare Vision Plan
The UnitedHealthcare vision plan offers vision benefits every 12 month.
In-network — Exams and standard lenses paid in full.
Adult frame allowance
Child under age 19 frame allowance
$100% coverage to $130, then tiered copay structure.
Out-of-network — Adults are reimbursed according to a fee schedule for exam, lenses and frames.
Children under age 19 are reimbursed according to a coinsurance schedule for exam, lenses and frames.
AxisPlus Flexible Spending Account Plan
AxisPlus offers health/dependent care spending accounts to pay for eligible expenses on a pre-tax basis.
Participating employees will receive an AxisPlus debit card that looks like a credit card and is issued under the MasterCard system and is
accepted at specific locations.
Use the debit card to pay for copayments and other qualifying expenses, and there is no more need to file claims for reimbursement
from the flexible spending accounts. (It is very important to keep your receipts when using the debit card since you must submit receipts
requested under IRS tax rules and regulations.)
A new card will be issued upon initial enrollment and at the expiration date shown on each card.
CVS Caremark Prescription Plan
Copayments for generic, preferred and non-preferred brand prescription drugs, per the following schedule:
30-Day Supply – Retail
90-Day Mail Order or
(Any Retail Pharmacy)
90-Day CVS/Pharmacy (only) Generics
Preferred brand prescription drugs
Non-preferred brand prescription drugs
Maintenance Choice Program – plan participants who take maintenance medications have the choice to purchase their 90-day supply
from the mail order program or purchase from a CVS/Pharmacy store and pay the same mail order copayment.
Mandatory generics when available as well as mandatory specialty pharmacy program for specialty prescription drugs.
Diabetic Meter Program – plan participants with diabetes may qualify for a free blood glucose meter when diabetic testing supplies are
ordered through the mail order program.
Delta Dental Plan
Dental coverage will be offered solely through Delta Dental, at three levels:
Delta PPO — You receive in-network benefits with no deductible, no forms to file and lower copayments.
Delta Premier — You are responsible for copayments and a deductible.
Out-of-network — You have a deductible to satisfy and need to file claims for reimbursement.
Standard Plan: $1,000 maximum benefit per covered person
Buy Up Plan: $2,000 maximum benefit per covered person
2015 – 2016 Benefits Information
AxisPlus, the New Flexible Spending Account Provider:
UnitedHealthcare Pilot Medical Necessity Program:
• Effective July 1, 2015, AxisPlus is the new Flexible
Spending Account (FSA) provider
• Effective July 1, 2015, certain services, tests or
procedures must be pre-authorized through the
Medical Necessity Process for the Choice Plus Plan
• AxisPlus will process medical and dependent care
claims for expenses incurred for plan year beginning
July 1, 2015
• Generally, when seeking services from a
UnitedHealthcare network provider, your network
provider will facilitate the Prior Authorization process
for you
• Employees who enroll in this plan will receive an
AXISPlus debit card to pay for eligible expenses
• Employees and covered dependents who receive
certain services from out of network providers are
responsible for obtaining the Prior Authorization by
contacting UnitedHealthcare
• You must enroll in the FSA every year. You may enroll
in this plan through Employee Self Service
CVS Prescription Plan Programs:
• Generic Step Therapy – effective July 1, 2015, you
and covered dependents will be required to try
generic alternatives first in certain therapeutic classes
before brand name drugs will be covered
• Additional information about the Medical Necessity
Program can be found on page 14 of this packet
• Detailed information on the services that will require
Prior Authorization will be provided in the Summary
Plan Description once it is updated for July 1, 2015
• If you choose to stay on your current, higher cost
brand name medication, you may have to pay the full
price if you have not tried a generic option to treat
your health condition
“Grandfathered Status”
Frederick County Public Schools (FCPS) has elected to be a
“grandfathered health plan” under the Patient Protection and
Affordable Care Act. As permitted by the Affordable Care
Act, a “grandfathered health plan” can preserve certain
basic health coverage that was already in effect when the
law was enacted. As a “grandfathered health plan,” FCPS is
not subject to certain consumer protections of the Affordable
Care Act that may apply to other plans.
• Additional information about Generic Step Therapy
can be found on page 13 of this packet
• Effective July 1, 2015, compound drugs will require a
prior authorization to be covered by the prescription
benefit plan
• A compound drug is made by combining, mixing, or
altering ingredients to create a customized medication
that is not otherwise commercially available
Summary of Benefits and Coverage
To comply with the Patient Protection and Affordable Care
Act (the Affordable Care Act), Frederick County Public
Schools provides a Summary of Benefits and Coverage
(“SBC”). The SBC can be found at the school system’s
website, www.fcps.org/benefits and paper copies
are available upon request. The SBC is intended to be
educational in nature. Complete details can be found in
the insurance companies’ documents and the plan’s legal
documents, which will always govern in case of a dispute.
• For select specialty drugs prescribed on or after July 1,
2015, you may be required to try a preferred product
prior to the non-preferred medication being dispensed
• Contact CVS Customer Service, 1-866-260-4646 if
you have questions or need additional information
about the new prescription drug programs
The premium rates and benefits included in this material are contingent upon final contract negotiations with FCTA,
FASSE, FCASA and final adoption of the Board of Education’s Fiscal Year 2016 budget.
JULY 1, 2015 – JUNE 30, 2016
UnitedHealthcare Medical,
UnitedHealthcare Vision,
CVS CareMark Prescription
(How much FCPS pays on your behalf)
Employee + One Dependent***
Dental – $28.81 per month ($345.72 per year)
Employee + Family****
Dependent Coverage
Employees + Family****
Medical – $576.79 per month ($6,921.48 per year)
Employee Only
(both parents employed by FCPS)
Employee Coverage
Medical – $644.96 per month ($7,739.52 per year)
Standard Delta Dental
$1,000 Maximum Benefit Per Covered Person
Buy Up Delta Dental
$2,000 Maximum Benefit Per Covered Person
Paid 100% by FCPS
Paid 100% by FCPS
Paid 100% by FCPS
Employee + One Dependent***
Employee + Family****
Employees + Family****
Employee Only
(both parents employed by FCPS)
*Payroll deductions are contingent upon final contract negotiations with FCTA, FASSE and FCASA and final adoption of the Board of Education’s Fiscal Year 2016 budget.
**Contributions for medical and dental insurance coverage are deducted from your gross earnings before taxes are calculated.
***In this context, “Employee + One Dependent” would refer to employee + spouse or employee + dependent.
****In this context, ”Family” refers to two or more dependents.
This publication is intended to provide an overview of FCPS benefits; complete details can be found in the insurance companies’ documents and the plans’ legal documents, which will always govern
in case of a dispute. The Board of Education of Frederick County, FCTA, FASSE and FCASA jointly reserve the right at any time to modify or amend, in whole or in part, any or all plan provisions.
Health/Vision Insurance
Phone & Website
Main Contact:
800 Oak Street
Frederick, MD 21703
Claims Office:
P.O. Box 740800
Atlanta, GA 30374-0800
Phone: 1-877-702-5116
P.O. Box 30978
Salt Lake City, UT 84130
Customer Service: 1-800-638-3120
Provider Locator: 1-800-839-3242
One Delta Drive
Mechanicsburg, PA 17055
Phone: 1-800-932-0783
Dental Insurance
Delta Dental
Flexible Spending Accounts
860 East 9085 South
Sandy, UT 84094
Phone: 1-877-872-2125
Claims Office
P.O. Box 52010
Phoenix, AZ 85072-2010
Phone: 1-866-260-4646
Mail Order
P.O. Box 94467
Palatine, IL 60094-4467
Fax: 1-800-323-0161
Prescription Plan
Phone Number
Benefits Office
Colette Baker
[email protected]
Phoebe Barreto
[email protected]
Kimberly Schaub
[email protected]
Shannon Thompson
[email protected]
Doris Toms
[email protected]
The HIPAA Privacy Rules require health plans to provide a Notice of Privacy Practices to persons covered under the health plan. Eligible
­employees may obtain a copy of the Notice of Privacy Practices by visiting the school system’s website: www.fcps.org. Go to Departments,
Human Resources, Benefits Links & Forms, HIPAA Privacy Statement. Employees may also contact the school system’s Benefits Office for a copy
of the privacy practice notice.
Questions concerning the HIPAA Privacy Rules may be directed to: Frederick County Public Schools
Colette Baker, Senior Manager, Benefits
191 South East Street, Frederick, MD 21701
Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have
a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children
aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual
insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or
CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible
for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out
how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your
employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity,
and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling
in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).
If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following
list of states is current as of January 31, 2015. Contact your State for more information on eligibility –
ALABAMA – Medicaid
Website: www.myalhipp.com
Phone: 1-855-692-5447
NEW JERSEY – Medicaid and CHIP
Medicaid Website:
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
ALASKA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
NEW YORK – Medicaid
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-800-541-2831
COLORADO – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Medicaid Customer Contact Center: 1-800-221-3943
Website: http://www.ncdhhs.gov/dma
Phone: 919-855-4100
FLORIDA – Medicaid
Website: https://www.flmedicaidtplrecovery.com/
Phone: 1-877-357-3268
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-755-2604
GEORGIA – Medicaid
Website: http://dch.georgia.gov/
Click on Programs, then Medicaid, then Health Insurance
Premium Payment (HIPP)
Phone: 1-800-869-1150
OKLAHOMA – Medicaid and CHIP
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
INDIANA – Medicaid
Website: http://www.in.gov/fssa
Phone: 1-800-889-9949
OREGON – Medicaid
Website: http://www.oregonhealthykids.gov
Phone: 1-800-699-9075
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 1-888-346-9562
Website: http://www.dpw.state.pa.us/hipp
Phone: 1-800-692-7462
KANSAS – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 800-792-4884
Website: www.ohhs.ri.gov
Phone: 401-462-5300
KENTUCKY – Medicaid
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
Website: http://www.scdhhs.gov
Phone: 1-888-549-0820
LOUISIANA – Medicaid
Website: http://www.lahipp.dhh.louisiana.gov
Phone: 1-888-695-2447
Website: http://dss.sd.gov
Phone: 1-888-828-0059
MAINE – Medicaid
Phone: 1-800-977-6740
TTY: 1-800-977-6741
TEXAS – Medicaid
Website: https://www.gethipptexas.com/
Phone: 1-800-440-0493
Website: http://www.mass.gov/MassHealth
Phone: 1-800-462-1120
UTAH – Medicaid and CHIP
Medicaid Website: http://health.utah.gov/medicaid
CHIP Website: http://health.utah.gov/chip
Phone: 1-866-435-7414
MINNESOTA – Medicaid
Website: http://www.dhs.state.mn.us/id_006254
Click on Health Care, then Medical Assistance
Phone: 1-800-657-3739
VERMONT– Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
MISSOURI – Medicaid
Phone: 573-751-2005
VIRGINIA – Medicaid and CHIP
Medicaid Website:
Medicaid Phone: 1-800-432-5924
CHIP Website:
CHIP Phone: 1-855-242-8282
MONTANA – Medicaid
Website: http://medicaid.mt.gov/member
Phone: 1-800-694-3084
Phone: 1-800-562-3022 ext.15473
NEBRASKA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 1-855-632-7633
Website: www.dhhr.wv.gov/bms/
Phone: 1-877-598-5820, HMS Third Party Liability
NEVADA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
WISCONSIN – Medicaid and CHIP
Phone: 1-800-362-3002
Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
WYOMING – Medicaid
Website: http://health.wyo.gov/healthcarefin/equalitycare
Phone: 307-777-7531
To see if any other states have added a premium assistance program since January 31, 2015, or for more information on special enrollment
rights, you can contact either:
U.S. Department of Labor
U.S. Department of Health and Human Services
Employee Benefits Security Administration
Centers for Medicare & Medicaid Services
1-866-444-EBSA (3272)
1-877-267-2323, Menu Option 4, Ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016)
A person to whom you are legally
Provide all of the following:
• Copy of official marriage certificate
• Copy of most recent Federal Tax Form (1040
or 1040A)* that identifies employee-spouse
(1st page only & black out financial information)
*If marriage occurred in current year, Tax Form is not needed.
• Dependent children until they
reach age 26
Natural Child:
• Copy of child’s official state birth certificate
Step Child – Provide all of the following:
• Copy of child’s official state birth certificate (must
name spouse of employee as the child’s parent)
• Copy of official marriage certificate
• Copy of most recent Federal Tax Form (1040
or 1040A)* that identifies employee-spouse
Legal Ward or Court Appointed Guardianship –
Provide all of the following:
• Copy of dependent’s official state birth certificate
• Copy of legal ward court document, with presiding
judge’s signature and seal
Adopted Child:
• Copy of official adoption papers, must indicate
child’s date of birth
Child for whom the court has issued a QMCSO
• A copy of the Qualified Medical Child Support
• Unmarried dependent children
over the age limit if:
1. They are dependent on you for
primary financial support and
maintenance due to a physical
or mental disability
2. They are incapable of selfsupport
Provide all the following:
• Completed Disability Form (Request from Benefits
• Copy of most recent Federal Tax Return
Medical and Dependent Care Flexible Spending
Section 125 Cafeteria Plan
A Flexible Spending Account (FSA) is an IRS program
which allows participants to pay for qualified Medical and
Dependent Care expenses with pre-tax dollars.
During your employer’s open enrollment you estimate your
expenses and make an annual election amount. Uniform
throughout the plan-year and are contributed to your FSA.
When you incur expenses simply swipe your AxisPlus® debit
card, or file a reimbursement claim with AxisPlus Benefits™,
and we’ll reimburse you directly from your FSA.
There are three types of FSAs: Health/Medical, Dependent
Care and what’s called a Limited FSA. The Medical FSA
covers out-of-pocket medical, dental, and vision expenses.*
The Dependent Care FSA reimburses dependent care
related expenses such as child daycare. Because they
are two separate accounts, money cannot be exchanged
between them. The Limited FSA exclusively reimburses for
out-of-pocket dental, vision or preventative care expenses.
Limited FSAs work well with Health Savings Accounts.
*See the Common Eligible Medical Expenses list on page 4.
AxisPlus Benefits™ | p 3
deductions are made from each paycheck (pre-tax)
Cafeteria Plan At A Glance
Frederick County Public Schools
One of the many benefits of being employed
with Frederick County Public Schools (FCPS)
is that you have access to a Cafeteria Plan
established by FCPS. A Cafeteria Plan
allows you to pay for out-of-pocket medical
expenses. The major advantage of FCPS’s
Cafeteria Plan is that, by participating, you
save money by paying for benefits you would
normally pay for but you avoid having to pay
Federal Income and Social Security taxes. If
you do participate in the Cafeteria Plan you
would not be eligible for a Federal income tax
credit on your next tax return.
FCPS’s Plan Information
Plan Name:
Frederick County
Public Schools
191 South East St.
Frederick, MD 21701
(301) 644-5112
Plan Number:
Plan Year Begin:
July 1
Plan Year End:
June 30
Maximum Health
FSA Limit:
Dependent Care
Annual Rollover
Grace Period:
Run-out Period:
90 days for
active employees
and terminated
to newly hired employees or those with
special circumstances (see Summary Plan
Document). For mid-year enrollments,
participation will begin on the 1st of the
month following hire date.
Beginning and Ending of Coverage
The coverage will begin the first day of
the Plan Year for those who enroll during
the open enrollment period. For mid-year
enrollments the coverage date will begin
as set forth by FCPS (see eligibility). The
coverage will end at the end of the month
of the termination date, or at the end of any
applicable run-out/carryover period. This
plan is subject to COBRA (see the Summary
Plan Description for more details).
Benefits Available
The FCPS Cafeteria Plan offers the following
Health Flexible Spending Account
A Health Flexible Spending Account (FSA)
allows you to get reimbursed for qualified
medical expenses with pre-tax funds (see
Section 213D and Section 105 of the Internal
Revenue Code for list of eligible expenses.
You cannot use your FSA for expenses that
have been paid by your medical insurance
plan.) The maximum annual election amount
is $2500.
Dependent Care Flexible Spending Account
Service Provider:
AxisPlus Benefits
Service Provider
Lacey Johnson
The Dependent Care Flexible Spending
Account (DCAP) allows you to be reimbursed
for qualified dependent day-care expenses
with pre-tax funds. The maximum annual
election amount is $5000 (married filing
jointly or head of household) or $2500
(married filing separately). To be eligible for
reimbursement you will need to provide a
statement from the service provider with
the following information: name, address,
taxpayer identification number (in most
cases), and incurred expense amount.
Please see the Summary Plan Description for
dependent eligibility requirements.
It is important for you to decide what benefits
you will need for each Plan year. Your decision
should be carefully made based on your
expected health expenses for the coming
Throughout the Plan year you can submit
for reimbursement for qualified medical and
dependent care expenses in the following
ways: fax (forms available at myaxisplus.
com), email, online, or mobile application.
Employees may also pay for their qualified
medical expenses directly from their FSA
with the AxisPlus debit card. See the SPD for
further details.
Unless a qualifying “change in status” event
occurs, you will not be able to change your
elections after the first month of the Plan
year. To see a list of the qualifying “change
in status” events please see your Summary
Plan Description.
Open enrollment will take place each year
prior to the start of the Plan year. After
the Plan year begins enrollment is limited
Expenses are “incurred” when the service
has been provided. The reimbursement
requirements will be listed on the
reimbursement claim forms.
For Health FSA and DCAP accounts
reimbursement claims must be submitted no
later than 90 days after the end of the Plan
Year. Any Health FSA funds exceeding $500
left over after the 90 day run-out period will
be forfeited. See “Rollover” section below for
additional details.
Non Discrimination
Per compliance with the various rules and
regulations of the Internal Revenue Code the
election amounts of “highly compensated
employees” and “key employees” (officers,
shareholders or highly paid employees)
may be limited due to non-discrimination
regulations. For more information please see
the Summary Plan Description.
Family and Medical Leave Act
If you go on a qualifying FMLA Leave this plan
will comply with the rules and regulations set
forth in the proposed Regulation 1.125-3 as
well as any additional policies established
by FCPS. Please see the Summary Plan
Description for more details.
Under the new IRS regulations, employees
will be able to rollover up to $500 of their
Health FSA funds from one Plan year to the
next. The rollover funds will be available
to employees for one additional year. Any
amount rolled over will not affect the election
amount for the new Plan year. Any funds
above $500 left over after the 90 day runout period will be forfeited.
Flexible Spending Frequently Asked Questions
What is a Flexible Spending Account (FSA)?
Flexible Spending is an employer sponsored program that allows you to set aside money pre-tax to use for certain IRS
eligible expenses. The Medical FSA covers not only medical expenses, but also dental and vision services.
How does an FSA work?
During the open enrollment period with your employer, you will make an election for the amount you want contributed to
your FSA. That annual amount will be divided equally over your yearly pay schedule, and deductions will be made pretax from each pay check and deposited to that account. As you incur expenses, you will submit for reimbursement from
your account, either with a paper claim or with the AXISPlus debit card.
What are the advantages to having an FSA?
When you participate in the Flexible Spending program, your eligible expenses are paid for with tax-free money. Also, as
the contributions are withheld from your paycheck pre-tax, it lowers your taxable income, meaning you pay less in taxes,
and take more money home.
What are considered eligible expenses?
There are 3 things to consider as you determine whether an expense is eligible for reimbursement from your Medical
FSA – services, service dates, and eligible dependents.
Services- Eligible medical expense are defined by IRS Code §213(d) and must not be excluded by the plan
documents. In order to qualify for reimbursement, the expense must diagnose, cure, mitigate, treat, or prevent
disease, or affect a structure or function of the body. Expenses aimed at maintaining general health or
improving a person’s appearance (cosmetic procedures), are not considered eligible expenses.
Service Dates- In order to be eligible for reimbursement, services must be provided/incurred during the time
that you are covered and active under the plan. The IRS is concerned with the actual date of service, not the
date of payment.
Eligible Dependents- Coverage for a Medical FSA is extended to the employee, the employee’s spouse, and the
employee’s child who is under age 26 or someone else who is a qualified tax dependent
of the employee.
When can I enroll?
You may enroll in the plan during your employer’s open enrollment period prior to the start of the plan year. You may
also enroll mid-year if you are a newly hired employee, or if you have a qualified Status Change Event as outlined in the
Summary Plan Description.
Can I make changes to my account mid-year?
Once you make your election during the enrollment period, it cannot be changed or cancelled during the plan year, it is
irrevocable. Exceptions to the irrevocability rule are allowed mid-year with a qualified Status Change Event such as a
marriage, divorce, birth, adoption, death, etc. The election changes must be consistent with the status change.
What if my spouse has a Health Savings Account?
If your spouse is participating in a Health Savings Account (HSA), participation in this FSA may disqualify them from
further contributions to that HSA.
What happens to money left in the account at the end of the plan year?
Under new IRS regulations, employees are now able to rollover up to $500 of their Health FSA funds from one plan year
into the next. This will allow participants an additional 12 months to spend the remaining balance. Funds that are rolled
over will not affect election amounts for the new plan year. A Run-out period will still be applicable, allowing you time
to submit reimbursement claims for expenses incurred prior to the end of the plan year. Rollover does not apply to the
Dependent Care FSA.
Do I have to wait for the money to be deposited before requesting reimbursement?
With a Medical FSA, you do not have to wait for the deposits to be made before requesting reimbursement. Your full
annual election amount is available to you on the first day of the plan year.
Flexible Spending Frequently Asked Questions Cont.
What information do I need for reimbursement?
In order to verify the eligibility of an expense, we need a third party statement indicating the provider’s name and
contact information, the patient, the date of service (not the date of payment), a description of services rendered, and
your portion of the expense. You should also retain a copy of the statement for your records.
How do I submit a reimbursement claim and when can I expect payment?
Reimbursement claims may be submitted electronically with the “Online Claims Entry” option on your account through
www.myaxisplus.com. Reimbursements may also be submitted with a printed reimbursement claim form and sent to
our office via email, fax or postal service. Reimbursement claims will be processed daily.
Where can I find out my account information and balance?
As a participant, you will have access to a secure online account through www.myaxisplus.com. Here you will be able to
view your account history and balance, submit reimbursement claims electronically, view eligible expenses lists, print
various forms and documents, and much more. You will be provided the online registration information after enrollment.
AXISPlus Debit Card
What is the AXISPlus debit card?
The AXISPlus debit card is a MasterCard® debit card that offers you direct access to your FSA funds.
How does it work?
You may swipe your AXISPlus card as you would any other debit card at a qualified medical merchant. The merchant
must accept MasterCard® as a form of payment. The funds will be debited from your Flexible Spending Account and
paid directly to the service provider.
Where can I use it?
The use of the AXISPlus card is limited to providers with a qualified medical Merchant Category Code (MCC). These
include doctor’s offices, hospitals, pharmacies, dental offices, and vision clinics. The card will not be accepted at an ATM
or for cash back on a purchase.
What if I lose my card?
From your account on www.myaxisplus.com you have the capabilities to report your AXISPlus debit card as lost or
stolen and to order a replacement card.
Can I have additional cards?
All enrollees will automatically be issued one debit card at the start of participation in flexible spending. Any additional
or replacement cards my be ordered through AxisPlus Benefits.
Will I need to send in any paper work?
Under the IRS regulations, we are required to verify the eligibility of every expense, whether paid with a reimbursement
claim or the AXISPlus debit card. There are various check-point systems in place to greatly reduce the amount of
documentation you will be required to submit to our office as you use the debit card, but it does not eliminate the
need for paper work entirely. The information requested will be the same as that of a reimbursement claim (see What
information do I need for reimbursement? above).
For each card swipe, you will receive automatic email notifications. These notifications will inform you of the status of
the transaction, and whether or not additional information/documentation is being requested.
What happens if a card payment is ineligible?
If all or a portion of your AXISPlus debit card transaction is deemed ineligible, you will be required to pay back the
ineligible amount to your Flex account. This can be done in a variety of ways and our staff will help you find the option
best suited for you. Please be aware that while there is money due on your account, your debit card will be temporarily
suspended until all transactions are either paid back or resolved.
Generic Step Therapy & You
Your first step on the path to better health for less
Welcome to the CVS Caremark Generic Step Therapy program. This program helps you and your
doctor choose a lower-cost, generic medicine as the FIRST STEP in treating your health condition.*
Just because a medicine costs more doesn’t mean it works better. Some health conditions have many
treatment options that vary in cost. Generic Step Therapy helps make sure the medicines that are
effective and priced right are used first.*
It makes sense to try a generic medicine as the first step in treating your health condition.
Why? Because for many people, they work just as well as other medicines but can cost up to
80 percent less.**
With Generic Step Therapy, if you choose to stay on your current, higher-cost brand-name medicine,
you may have to pay the full price if you have not tried a generic option to treat your health condition.†
For some health conditions, you may have to try two generic options, depending on your plan.
Why pay more to treat your condition when a generic medicine may provide the same
health benefits for less?‡
Remember, lower cost does not mean lower quality. Choose a generic medicine and treat your health
condition for less!
How Do You Take The First Step?
Talk to your doctor to
find out which lower-cost,
generic options may be
right for you
Ask your doctor to call in your
new prescription(s) to:
• Retail pharmacy: Find one
included in the CVS Caremark
Network at www.caremark.com
• CVS Caremark Mail Service
Pharmacy: Your doctor can fax,
e-prescribe or call toll-free at
Fill your new
prescription(s) and treat
your health condition
for less!‡
Want To Learn More?
Learn more about Generic Step Therapy by watching this short video: www2.caremark.com/
sitetour/steptherapy/. You can also visit Caremark.com and click “Find Savings and Opportunities” OR
call the toll-free number on the back of your prescription ID card. We are ready to help!
*Lower-cost options are generally generic medicines.
** Generic Pharmaceutical Association website: http://www.gphaonline.org/about-gpha/about-generics/case.
† Your doctor can contact CVS Caremark to request a prior authorization if you have a unique medical situation that requires you to keep taking
the higher-cost (brand-name) medicine. If you have previously taken generic medicine in the same drug class, you may not be affected by this
‡ Your savings will vary based on your plan and/or medicine prescribed.
©2013 Caremark. All rights reserved.
5295-28807a 080613
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
Medical Necessity
Frequently Asked Questions
We believe that both members and providers (physicians and other health care professionals, hospitals
and clinics) can be supported in making informed health care decisions by sharing information about what
services, tests or procedures are considered clinically appropriate in accordance with Generally Accepted
Standards of Medical Practice.
UnitedHealthcare offers both members and providers this information, based on credible scientific evidence
published in peer-reviewed medical literature and generally recognized by the relevant medical community,
through the Medical Necessity process.
With this information, we seek to support you and your doctor as you decide what steps to take.
Q1: What is medical necessity?
A1: Based upon a foundation of evidence-based
medicine, Medical Necessity is the process for
determining benefit coverage and/or provider payment
for services, tests or procedures that are medically
appropriate and cost-effective for the individual member.
The Medical Necessity process:
 Provides an opportunity to address covered services
at the individual level to support enhanced access to
quality care for the member.
 Utilizes generally accepted standards of good
medical practice in the medical community.
 Offers communication between health plans,
members and providers, allowing for prospective,
concurrent and retrospective review as well as appeal
rights for adverse determinations.
Q2: What are the benefits of determining
whether a service is medically necessary?
A2: Medical Necessity uses advancements in medical
practice standards based on scientific evidence and
Generally Accepted Standards of Medical Practice.
Medical Necessity is designed to combine these
advancements in health information technology to
address differences in care and promote efficient delivery
of high quality care in a cost-effective manner.
Q3: What is prior authorization?
A3: Prior Authorization is the process of determining
benefit coverage prior to a service being rendered to an
individual member. A determination is made based on
Medical Necessity criteria for services, tests or procedures
that are appropriate and cost-effective for the member.
This member-centric review evaluates the clinical
appropriateness of requested services in terms of the type,
frequency, extent and duration of stay.
Q4: How is Prior Authorization different from
the current Care Coordination process in some
UnitedHealthcare plans?
A4: Going forward, coverage determinations for those
members on the appropriate benefit plan will use
Medical Necessity criteria. To support this change, we are
introducing language in our new Certificates of Coverage
and Summary Plan Descriptions which expands the
definition of a covered service as one that is medically
necessary. Services determined to be not medically
necessary during the pre-service review process will be
the member’s liability (assuming a determination of
non-coverage was rendered and communicated prior
to the date of service and a specific member attestation
is on file with the provider).
Q5: Where can I find the requirements for
services and procedures that require Prior
A5: Prior Authorization requirements will be listed
in the Certificate of Coverage and Summary Plan
Q6: How are the services outlined in the
UnitedHealthcare Prior Authorization
requirements selected?
A6: The Prior Authorization requirements reflect
those services where data demonstrates significant
variation in care being delivered and the clinical
efficacy of the treatment.
Q7: What clinical criteria will UnitedHealthcare use to
determine Medical Necessity?
A7: UnitedHealthcare uses Generally Accepted Standards of
Medical Practice, which are based on credible scientific evidence
published in peer-reviewed medical literature and are generally
recognized by the relevant medical community. We may also
use standards that are based on physician specialty society
recommendations or professional standards of care, or other
evidence-based, industry-recognized resources and guidelines,
such as the Milliman Care Guidelines®, to determine Medical
Necessity and appropriate level of care.
Q12: When am I responsible for the cost of services?
A12: You are responsible for the cost of services in the
following situations:
1. The service is deemed not covered or not medically
necessary in accordance with your benefit plan, and the
determination was communicated before the service was
rendered and you have given your provider an attestation
acknowledging your responsibility for the service.
2. You were responsible for obtaining Prior Authorization,
but failed to do so.
3. During an inpatient (overnight) stay in a hospital or
facility, an inpatient day is determined to be custodial.
Custodial care includes any of the following services:
Q8: Who is responsible for obtaining Prior Authorization?
A8: Generally, members in plans with Prior Authorization
(e.g., Choice, Choice Plus, Navigate) can rely on their network
physician to obtain Prior Authorization for services on the
standard Prior Authorization requirements list. Members will
be responsible for obtaining Prior Authorization if they access
a non-network provider, are in a product accessing our Options
PPO network (i.e., Options PPO, Non-Differential PPO), or
if the service is on a customer-specific (non-standard) Prior
Authorization requirements list.
activities of daily living (examples include feeding,
dressing, bathing, transferring and ambulating).
primary purpose of meeting the personal needs of the
patient or maintaining a level of function (even if the
specific services are considered to be skilled services),
as opposed to improving that function to an extent
that might allow for a more independent existence.
Q9: What should I do before receiving services that
require Prior Authorization?
A9: 1. Contact UnitedHealthcare to request Prior
Authorization if you are responsible for obtaining
Prior Authorization (see Question and Answer above).
by trained medical personnel in order to be delivered
safely and effectively.
2. Review your Prior Authorization letter to make sure the
services that are approved are the same as those you are
expecting to receive and confirm this with your provider.
Q13: Are there any changes to the appeal process?
A13: UnitedHealthcare will continue to adhere to all applicable
federal and/or state appeal requirements for members.
Q10: What process should I follow to obtain Prior
A10: Your Certificate of Coverage or Summary Plan
Description sets forth the process you should follow for
benefits that are subject to the Medical Necessity Prior
Authorization process.
Q14: Who can I contact if I have more questions?
A14: Please call the Customer Care number on your health
plan ID card.
Q11: How will I be notified of the outcome of a Prior
Authorization request?
A11: UnitedHealthcare will mail a letter to you and your
physician for all Prior Authorization requests. If a non-coverage
determination is rendered, an Adverse Benefit Determination
letter will be generated and will include an explanation for the
determination, criteria used and appropriate internal appeal and/
or external review rights.
Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by UnitedHealthcare Insurance
Company, United HealthCare Services, Inc. or their affiliates. Health Plan coverage provided by or through a UnitedHealthcare company.
100-10959 10/11 © 2011 United HealthCare Services, Inc.

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